Provider Demographics
NPI:1114230943
Name:GOODYEAR, EMILIE (MDCM)
Entity Type:Individual
Prefix:DR
First Name:EMILIE
Middle Name:
Last Name:GOODYEAR
Suffix:
Gender:F
Credentials:MDCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 493
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-625-4400
Mailing Address - Fax:612-626-3119
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 493
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-625-4400
Practice Address - Fax:612-626-3119
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52783282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren